RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01391
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150724
SEPARATION DATE:  20040701  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Culinary Specialist) medically separated for left knee and right ankle conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  Two left knee diagnoses “left knee osteoarthrosis” and “status-post [s/p] arthroscopic surgery...” and two right ankle diagnoses “right ankle arthritis, s/p osteophyte reaction” and “right ankle grade III anterior impingement...” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted.  The Informal PEB adjudicated “left knee osteoarthritis” (with the second diagnosis as an associated Category II condition, a condition contributing to the unfitting condition) and “right ankle arthritis” (with the second ankle diagnosis also as Category II) as unfitting, rated 10% each, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  His conditions have worsened and negatively impact his daily activities.  His complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  
                                                          
IPEB – Dated 20031106	VA* - ~5 months Pre-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Osteoarthritis	5003	10%	Left Knee ... Meniscus Tear ...	5010-5259	10%	20040212	
S/P  Arthroscopic Surgery ...	Category II	No VA Rating	
Right Ankle Arthritis	5010-5003	10%	Osteophytes Right Ankle ...	5010-5271	10%	20040212	
Right Ankle Impingement ...	Category II	No VA Rating	
Other x 0 (Not In Scope)	Other x 14 	
COMBINED RATING:  20%	COMBINED RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20040802 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  
  
Left Knee.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an atraumatic onset of left knee pain several years prior to separation.  Two arthroscopic surgical interventions ensued, the last one in August 2001 (nearly 3 years prior to separation), consisting of debridement of damaged cartilage (osteochondral defect).  The STR documents continued pain and limited improvement with conservative measures.  Various STR entries documented grossly normal range-of-motion (ROM) with measured flexion ranging from 120-130 degrees (normal 140, minimum compensable 45) and extension (one entry) to -2 degrees (normal 0, minimum compensable -10).  Several entries noted some mild loss of strength (4/5, although others record 5/5), and one documented an antalgic gait.  Multiple STR entries documented joint stability to stress testing, the absence of effusion, and negative signs of impingement; with none to the contrary.  There was an X-ray confirmation of degenerative changes and no STR documentation of periods of incapacitation.  The NARSUM exam conducted on 19 August 2003 (10 months prior to separation), documented continued knee pain since surgery with limitation of running, stair climbing, and prolonged walking or standing.  The physical exam noted that the CI “moves gingerly” and recorded tenderness without effusion, patellar grinding, no instability, and no signs of joint impingement.  The ROM was documented as “full.”  

A VA Compensation and Pension (C&P) examination conducted on 12 February 2004 (5 months prior to separation), documented constant “sharp pain and stiffness” prohibiting “running, climb stairs, walk or prolonged standing or bending.”  The VA physical examination recorded an antalgic gait, the absence of effusion, no instability, and no signs of joint impingement.  The VA measured ROM was flexion 120 degrees and extension 0 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  It is first clarified that the PEB’s Category II diagnosis (surgical residuals) is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was compliant with VASRD §4.71a criteria for the ROM and ratable findings in evidence.  The VA’s coding choice of 5259 (cartilage, semilunar, removal of, symptomatic) was a good clinical fit and yields a 10% rating (no higher rating offered) without regard to additional criteria.  There is no evidence for compensable ROM impairment, frequent effusions, or locking which would support a rating higher than 10% under any applicable code; and, no grounds for additional rating of instability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left knee condition.

Right Ankle.  The STR documented an onset of atraumatic right ankle pain in early 2002.  The CI underwent surgical intervention (arthroscopic debridement) in September 2002 (22 months prior to separation), but the pain persisted and it was ultimately recommended that this condition be added to the MEB in progress for the knee condition.  Measured ROM soon after surgery was dorsiflexion (DF) to ~10 degrees (normal 20) and plantar flexion (PF) to 40 degrees (normal 45); and, an STR entry from July 2003 (12 months prior to separation) recorded ROM measurements of PF to 45 degrees and DF to 15 degrees.  Various entries documented joint stability to stress exams, but an ankle brace was periodically used.  There was X-ray confirmation of degenerative changes and no STR documentation of periods of incapacitation.  
An addendum to the NARSUM addressing the right ankle condition was dated 27 August 2003 (10 months prior to separation), and documented “throbbing pain still which occasionally is about a 6/10” without elaboration of limitations or physical examination findings.  The above ROM measurements from the STR were cited.  

The VA C&P examination (same as referenced for knee condition) documented “pain, stiffness, aching, and weakness ... on a daily basis” which prohibited “prolonged standing or running.”  The physical exam recorded “normal” appearance of the ankles without comment regarding joint tenderness or stability.  The VA ROM measurements were PF to 20 degrees and DF to 15 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The associated Category II diagnosis is subsumed with the primary rating as elaborated for the knee condition.  The PEB’s 10% rating analogous to 5003 was compliant with §4.71a criteria for the ROM and ratable findings in evidence.  The VA’s 10% rating under code 5271 (ankle, limitation of motion) was for “moderate” limitation, and 5271 offers 20% for “marked” limitation.  Members agreed that the ROM limitation in evidence is more reasonably characterized as moderate, not marked.  No criterion is supported by the evidence which would satisfy a rating higher than 10% under any other applicable code available in VASRD §4.71a.  After due deliberation, considering all evidence with deference to reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the right ankle condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left knee condition (subsuming the Category II diagnosis specified above) and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right ankle condition (subsuming the Category II diagnosis specified above) and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 4 Aug 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN